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/ `pPQ�-COC SAN 1QA Y <br /> � ,, Z,l USN Environmental Health Department <br /> L —COU NTY--- <br /> S�„ ".-'' Greatness grows h._;._. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name ` A Lic. Plate# .������� <br /> Owner/Operator Name L L&Jd4 c15 <br /> Business Mailing Address J32Z- g, l td i t'. o-vt Le )o,)4 RD�. �. <br /> city s "_State6aZip_9AL2f:1Bus. Ph..Z09 q.4 / It. Ph. <br /> I, hd4 th I I�gp , hereby state that the above information is current,true and correct to <br /> the best of my knowledg ae nd agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocationnapd penalties. I n <br /> Signature7�/ LUIs E- �C �t 0.S Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name LQ1101610k CAkeY\)4 Lf ash FA#_Z O(A- N 10 I -G 10-1 <br /> Address-13O S. CC640V- 0 Sk- Bus. Phone gLOG --2,711-1-H 1 <br /> C45to(, M V\ Zip%W I Owner/OperatorS0jVQd0ir gUlhr0b}M '. Cu Y m 4 h <br /> Check all appropriate services provided: 1?1 V <br /> Ila Wastewater disposal y7 3-compartment sink Electrical hook-ups <br /> * Solid waste disposal Q Food preparation Toilet and handwashing <br /> * Hot & Cold water for cleaning 99 Store refrigerated food ® Potable water <br /> §1 Store dry food/supplies ® Overnight parking Q7 Vehicle wash <br /> I, Sinii- DUeloblIvo , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa=1na44:M_,: <br /> D imn /1 <br /> SignatureDate <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uih Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />